Coalition seeks funds for HCV/HIV co-infection
Integrating services makes economic, medical sense
After years of neglect, efforts are building to form a coalition that will draw more attention to the treatment and care needs of patients co-infected with HIV and hepatitis C virus (HCV). And while federal and state funding for HCV has remained flat or is being cut, health experts say integrating services is not as demanding as is often assumed.
The National AIDS Treatment Advocacy Project (NATAP) in New York City is in the initial stages of organizing a national coalition to promote awareness of HCV/HIV co-infection, which began with a legislative briefing in late March that touched on lack of funding for national programs, the disproportionate co-infection rates among minorities, and barriers to treatment and care.
"We are tying to bring the issues onto the table that co-infected patients deal with, because a lot of the public is not aware of the problems," says Nadia Cohen, NATAP spokeswoman.
An estimated 4 million Americans are infected with HCV. Among HIV-infected persons, studies indicate that up to 40% also are infected with HCV, increasing to 60% to 90% among injection drug users. Moreover, liver diseases associated with HCV have become the leading cause of death in HIV-positive patients.
Hepatitis B virus (HBV) also has re-emerged as a growing problem in HIV-positive people. A prevalence study presented at the 10th Conference on Retroviruses and Opportunistic Infections in Boston, found that 65% of 240 patients enrolled in the AIDS drug treatment study either had past or active infection with HBV.1
Despite the medical and financial burden of co-infection, NATAP faces an uphill battle in its efforts to increase funding. HCV funding for the National Institutes of Health has remained fairly flat, with $95 million earmarked in 2002, $104 million projected for 2003, and $108 million for 2004. The Centers for Disease Control and Prevention (CDC) budgeted only $21 million for HCV last year.
Short of the resource question, there are few arguments for not integrating viral hepatitis services into HIV clinics, say public health officials. Yet for various reasons, including uncertainty of demand and the need to retrain staff, integrating viral hepatitis services is a public health goal that most clinics haven’t embraced, public health officials tell AIDS Alert.
"A one-stop shop for putting services together for viral hepatitis and HIV is good public health and the way things ought to be," says Steve Jones, MD, associate director of science for the CDC’s Division of HIV/AIDS Prevention. "I’d even say it’s bad public health not to do it."
Texas program integrates testing
While most states lack hepatitis plans, some have become models for how HCV screening can be incorporating into existing HIV prevention programs. Benefiting from a strong advocacy response at the grass-roots level, coupled with background information provided by the state health department, Texas has been offering HCV screening at its HIV counseling and testing sites for the past three years. In 2000, the state legislature approved nearly $3 million to conduct seroprevalence studies, establish education programs, and integrate hepatitis screening into its 72 HIV counseling and testing sites, which test about 140,000 people each year. The appropriation came despite flat funding for other public health programs.
The Texas Department of Health’s push for HCV screening followed a federal retrospective HCV study of blood donors in the early 1990s. That effort identified the need for a more broad-based, practical approach to hepatitis prevention. The health department published a white paper on HCV and helped establish a working group of public health agencies and community-based organizations.
Educating key legislators and promoting strong community advocacy were crucial to getting the bill passed, state health officials say.
"The overall lesson has been that it makes a lot of sense — not just fiscal but programmatic — to offer both HCV and HIV screening simultaneously," says Felip Rocha, MSW, acting AIDS director for the Texas Department of Health in Austin. "You have the person in front of you, so you might as well serve them as comprehensively as possible."
The funding has been a good first step but hardly adequate for offering HCV services at all the state’s HIV counseling and testing sites. This year, $750,000 was earmarked for testing, which allowed only 21 sites — those with a high population of injection drug users — to offer testing, he says.
One of the biggest challenges has been allocating resources to get through each year, especially for testing costs. (The RIBA, recombinant immunoblot assay, test costs $150 in Texas.) Another concern has been screening for HCV yet not having resources for treatment. Now with the state’s budget crisis, the very existence of the program looks doubtful.
"It’s highly likely the program won’t be renewed, and that is unfortunate," Rocha adds.
With limited funds, the state health department had to train staff as efficiently as possible. The department decided early on not to create a new model but rather modify existing prevention counseling guidelines.
For example, the department’s four-day training course for sexually transmitted disease (STD) and HIV prevention counseling was modified to include all aspects of viral hepatitis. Through the CDC’s STD Prevention Training Center in Dallas, two clinical updates were provided each year, giving up to 150 counselors a two-day overview of HCV, including video showing examples of HCV client-based counseling.
The main goal was to reinforce the fact that skills required for good HCV counseling are the same for HIV. In addition, the department had to modify its data collection forms submitted by the clinics so HCV data could be reported.
"The counselors have been able to make the adjustment remarkably well," Rocha tells AIDS Alert.
Funds for public education have been minimal, however, resulting in wide variability in the quality of information. Health officials had initial fears, which proved unwarranted, that the wrong messages could set off a "run" on testing sites. One public service message, for example, urged testing for anyone with a history of military experience, dental work, or immunization.
Before considering integration, HIV programs should consider whether demands for HCV testing, particularly those serving high-risk populations, could divert existing resources from HIV services. Specifically, partner services for infected clients could be a big drain on limited staff.
"It’s a real challenge to describe what your priorities are and how you’re going to allocate resources," says Casey Blass, the state’s former AIDS director, who helped start the program. "If you look at the prevalence, it would be easy for hepatitis C to overwhelm many sites, so we had to set up a system to preserve the infrastructure we had in place."
Reference
1. Sherman K. Shire N, Rouster S, et al. Prevalence of occult hepatitis B infection in HIV-infected patients: Analysis of a geographically distributed ACTG cohort. Presented at 10th Conference on Retroviruses and Opportunistic Infections. Boston; 2003. Abstract # 820.
After years of neglect, efforts are building to form a coalition that will draw more attention to the treatment and care needs of patients co-infected with HIV and hepatitis C virus (HCV). And while federal and state funding for HCV has remained flat or is being cut, health experts say integrating services is not as demanding as is often assumed.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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